EMERGENCY NEEDS ASSESSMENT IN WESTERN KENYA

After the first few weeks performing a needs assessment in and around Kisumu, Kenya, I'm getting the handle on the survey. I've managed to adopt a bit of an accent in order for the practitioners to understand me. And if I speak slowly enough, a true challenge for me, the language barrier is minimal. All the providers have been very helpful. At first, most seem a little skeptical and resistant to sit down with me for a full hour of interviewing. Eventually, they are able to find some time for our team and have a good conversation about their emergency care capabilities. Unfortunately, sometimes the conversation can run over sometimes, but that usually means we were laughing to much trying to get to know each other.

Dave Young, MD

Antenatal Ultrasound Training in Resource-Limited Regions of Western Kenya

 

Maternal mortality continues to be a significant public health problem throughout the developing world.  Sub-Saharan Africa accounts for approximately 50% of all maternal deaths globally.  World Health Organization data suggests that the majority of these deaths could be prevented if emergency obstetric care were available at every birth. However, since almost half of all births in developing countries take place at home without a skilled birth attendant, life-saving obstetrical interventions are often delayed.  This results in unnecessary maternal and fetal morbidity and mortality.

 

A new generation of affordable, hand-held ultrasound machines has opened the possibility for antenatal ultrasound screening programs in resource-limited settings, such as rural Kenya.  However, given the general paucity of radiologists in Kenya, the training of non-radiologist clinicians in point-of-care ultrasound is essential.  I had the pleasure of working with the Division of Global Health and Human Rights and Kisumu Medical Education Trust, our in country partner, to train midwives in point-of-care maternal ultrasound in Western Kenya.

 

Working with an ultrasound-trained Emergency Room physician from California and three Kenyan midwives with subspecialty training in ultrasound, we provided one week of refresher training in antenatal ultrasound to 16 nurse midwives from all over Western Kenya.  The midwives participating in the refresher course had received initial antenatal ultrasound training through our program nearly 1 year prior.  In the mean time they had integrated limited antenatal ultrasound services into their rural obstetrical practices.

 

 

It was great to reunite with the midwives whom I had worked with before and to meet and hear the stories of those midwives whom I was meeting for the first time.  These dedicated health care providers shared powerful stories of how ultrasound had impacted their patients in positive ways.  By identifying high-risk conditions early (i.e., placenta previa, twin gestation, and abnormal presentation), providers could arrange hospital delivery for these patients.  In the absence of these ultrasound-based diagnoses, these patients may have delivered at home, potentially resulting in untreated complications of delivery.

 

 

Overall, I feel blessed to have had the opportunity to participate in the amazing ultrasound work happening in Western Kenya.  Recently, the Kenyan Ministry of Health decided to provide free hospital-based labor and delivery care to any woman in Kenya who desired it – effectively eliminating another barrier to safe perinatal care for Kenyan women.  I look forward to continuing my participation in this important mission and thank the Partners Center of Expertise in Global and Humanitarian Health for helping to make it possible.

 

H. Benjamin Harvey, MD, JD

Resident

Department of Radiology

Massachusetts General Hospital

OB/GYN MGH/MRRH Collaboration

I’m now almost at the end of my first trip to Mbarara Regional Referral Hospital. It’s been quite the whirlwind and time always flies so fast.  As I’ve gotten to know this hospital and in particular the obstetrics and gynecology department I have realized there is a trail of hospital equipment that tells the tale of visitors past and perhaps present.

On the antenatal ward for example I came across two digital fetal doppler machines. These are handheld, very portable and useful in finding and listening to fetal heart tones in utero. They are essentially a digital replacement of the pinard (fetal stethescope).

Digital Fetal Doppler

As handy as the digital dopplers are, their portability and attractiveness were their downfall when it came to their use on the antenatal ward. Concerned about their inherent, “walkability”, the donors/department created small metal cages, with no openings and attached to the metal IV to host the handheld devices. Unfortunately this has meant that the devices cannot be cleaned, or the batteries changed, so now the devices simply sit there, tugged along whenever the IV pole is in use, but unable to perform their ascribed function. Fixing this issue seems a simple undertaking, but perhaps it is a measure of their lack of desirability by local clinicians that the dopplers continue to sit there, literally gathering dust, and the pinard continues to be the preferred mode of auscultation. Indeed although it may seem like the digital device is an improvement, this very scenario prompts me to question if there is any evidence that demonstrates one is better than the other and if such evidence is relevant in the local setting.

This picture of forlorn and non functioning equipment is seen again and again all over the hospital. Most often, it is not a simple matter to fix the equipment – the expertise or the parts needed are simply not available. In the medicine department for example, there are several donated light boxes with a similar fate. Each is made up of a box, with a white screen and a light bulb to illuminate – technology that is seemingly simple and therefore easily transferrable from one setting to another. Unfortunately these boxes are manufactured with specialized light bulbs with unique sockets and shapes that are unavailable locally, rendering the light boxes unusable once they burn out. Another example is seen in the operating rooms where I noticed several electrocautery machines sitting quietly in corners. They are handy when available, but clearly not essential, and without any local expertise trained in fixing them and almost no hope of company technicians coming out to fix them,  more than likely they will go on sitting in the corner -too expensive to discard, and yet not essential enough to find a solution to.

This is not to say that such equipment is unnecessary or fated to be relegated to an iron cage. I also saw several examples of machines both donated and bought integrated successfully into clinical care.  Nonetheless, the trail of quietly forgotten equipment should remind us to be careful in what we wish for or even in some cases introduce as visitors. It’s very easy to think that x instrument or y machine would make such a difference and let’s do what we can to get it here. It might even work for 6 months or perhaps 1 or 2 years, and perhaps that is worth it, but often it appears that they don’t even make it that far and clinicians revert to their known and perhaps more reliable methods.

Perhaps a more exciting and more sustainable approach is that taken by new institutions like CAMtech. Its stated goal is to “to improve and accelerate high-quality, affordable medical technology development for low- and middle-income countries (LMICs)”. CAMtech’s very first innovation lab is currently growing roots in Mbarara, Uganda.  I had the opportunity to see it in action when I went in search of their first engineer. 

Patrick Ssonko at CAMTech I was lucky enough to meet Patrick Ssonko.  He recently graduated from engineering school and just this past summer was hired as the engineer in house at CAMTech. Patrick's monitor in development  I was very impressed and encouraged by his enthusiasm, creativity and zeal. During my visit, he demonstrated his self developed heart rate and temperature monitor and even let me test it out. The instrument is in its early phases but the potential is huge. He plans to build in a component that can relay the values to a separate screen and more importantly have the ability to send text message alerts to clinicians. The potential for this kind of enterprise to positively impact clinical care in MRRH is huge. First of all if engineers like Patrick are connected to and collaborate with physicians and nurses working on the ground in Mbarara , devices created are much more likely to be directly applicable to the clinical setting within which they work. Home grown devices also likely mean cheaper components and more importantly that the replacement components and the local expertise on how to replace them are available.

Adeline Boatin, MD MPH

OB/GYN Global Health Fellow

Western Kenya - Maternal Ultrasound Screening Programs

This morning I landed in Kisumu, Kenya on a beautiful summer day. Kisumu is the third largest city in the country, located in Western Kenya on Lake Victoria. I traveled via tuk tuk (rickshaw) to the MGH guest house. The road was a little bumpy, as the major road to the airport was under construction. Sometimes the course of growth and development has bumps in the road, but the outcome is undoubtedly worth it.

 

After adjusting to the time difference, I woke up this morning ready for our first day in the field. Our research team embarked for Kaimosi to perform obstetric ultrasound screening. Kaimosi is a small town/village located 40 kilometers NNE of Kisumu. The drive through the Kenyan countryside was beautiful. The natural beauty helped distract me from the narrow, often unpaved roads that seemed quite treacherous at times.

 

Upon arrival, we met the hospital administrator who was very gracious. I had the opportunity to tour the hospital grounds and facilities. The resources were quite modest in terms of physical equipment and human resource availability. Additionally, one of the major challenges that the hospital faced was related to energy. The energy grid in the region was somewhat unpredictable. I learned that it was not uncommon for the hospital to go without power for 2 to 3 days at a time.

It was also clear that inpatient care within the hospital was a family endeavor.  Patient families were often present and assisting in caring for their loved ones. Family members would bring food, wash linens and clothes and attend to various needs that are customarily provided as part of inpatient care in the U.S.

As a radiology resident, I was specifically interested in the imaging equipment. While walking through the courtyard, I saw a radiographic film hanging on a clothesline. The film was still wet; the true origin of the term “wet read.”  In addition to plain film radiography, the hospital had a fluoroscopy unit which was used for barium studies.

Utilizing the portable ultrasound machine we brought, we were able to provide obstetric ultrasound screening examinations. The portability and durability of the ultrasound machine as an imaging tool in resource limited areas became quite evident.

 

 

 

 

MGH/MRRH OB/GYN Collaboration: Mbarara Uganda (Sep-Oct 2013)

I can’t say that I was shocked when I got to Mbarara Regional Referral Hospital.  I had been there before, so to speak,  only in a different country on the opposite side of the continent. I knew the stark and dramatic differences. I was however taken aback yet again. It was hard not to compare what I trained in and knew well with what I faced in Mbarara. At MGH we have 11 delivery rooms, each private, with large beds equipped with movable and removable parts. These accommodate 3000 deliveries a year. At MRRH they have 2 delivery beds. Simple steel frames with a thin black pad. 

Delivery bed on the Labour Ward at MRRH

These 2 beds take the hospital through over 8000 deliveries a year.  This most basic difference in physical resources is only just the beginning. In almost every aspect of patient care and management the residents and obstetricians at MRRH make do with so much less – almost zero nursing support, limited supply of drugs and equipment, limited antenatal records, often no dating of pregnancies, no electronic fetal monitoring, limited availability of neonatal resuscitation, limited or no oxygen. This list goes on and on.

Despite the limitations of medical care and lack of – almost everything physical, I have been most impressed by the abundance of fortitude and patience displayed by the women seeking obstetric care at MRRH. After a cesarean section, women simply get on with the necessities of life with very little support. To begin with, they get an astonishingly limited amount of pain medication. At MGH women routinely receive IV toradal, shortly followed by regular doses of oxycodone or dilaudid, which they not only have throughout their hospital stay, but also go home with. Here at MRRH, it is a dose or two of pethidine (demerol) immediately post op, and then rectal diclofenac as needed. That’s it, and no complaints - they just deal with it.  They go to the bathroom themselves, empty their foleys themselves, , provide for their own meals, own sheets, and own supplies as needed.  They get only the basics from the hospital – a “Mama Kit” which includes: a bar of soap, 2 plastic sheets (on which they have their vaginal exams and on which they deliver), a roll of cotton wool (which become their pads), 2 packs of gauze, 2 razor blades, and a health card for their child. 

Mama Kit Provided to Patients on Admission

On top of that, their recovery is far from comfortable.  In a postnatal ward built to accommodate 30 women, there are often as many as 60. When the beds run out, which they always do, women, post vaginal delivery or some even post-cesarean get a mat pad and make a space on the floor – either squeezed in between two beds or at the foot of the beds. This happens every day. In the time I have been here I have never seen any woman complain, argue or express the slightest irritation at being placed on the floor. If they are asked to move to allow a doctor or nurse to get to a patient or a piece of equipment, again no frustration or complaints they simply pick up their mats, their personal belongings and their babies and move.

Postnatal Ward at MRRH

Without a doubt these women display extra-ordinary fortitude in coping with their physical pain and in managing without many of the comforts and support that women in Boston taken for granted. Perhaps even more remarkable is the resilience shown by a significant portion of these women  recovering from a neonatal loss, or delivery of a stillborn child. At this hospital the stillbirth rate has ranged from over 2-6% of deliveries. That is as many as 58 stillbirths per month, with over half of those often occurring intrapartum. Women who have suffered these losses also simply go on, also squeezed into the postpartum ward, perhaps next to, or in between women who are fortunate enough to have their babies well and crying at their sides. Their expressions and demeanor often reveal little and it is so easy to walk past them, or even examine and assess them without recognizing or acknowledging their loss.

 On rounds one day I attempted to ask a woman where her baby was. I was with a resident from India and we both could not communicate well. The woman lying next to her listened to our fumbled attempts, and took pity on us.  She could speak English –“the baby is in the Toto ward” (pediatric ward), she said quite simply, “they’ve taken it for testing”.  We thanked her and continued with our assessment of that patient. About 5 minutes later we got to the woman who had helped us. She also had no baby. We asked and she said – her baby didn’t make it. It was born alive and died shortly afterwards. From our conversation 5 minutes earlier I would never have known. For this woman, I had the opportunity to acknowledge her loss, and express some amount of empathy – though from where I stood I clearly had no concept of how she really felt. I wondered how many other women I had walked past or assessed without any recognition or acknowledgement of their loss. Knowing the stillbirth and neonatal rates, that I had done so was a certainty. 

Adeline Boatin
OB/GYN Global Health Fellow

Durban, South Africa

Determining HIV-associated cryptococcal disease with clinic-based, point-of-care screening in Durban, South Africa.

In August, I traveled to Durban, South Africa to collect pilot data for a study of diagnostics and to set up a new study related to cryptococcal infections, a common cause of HIV-related mortality.

The global burden of cryptococcal meningitis (CM) is estimated at 958,000 cases and 625,000 deaths per year, making CM a leading cause of AIDS-related mortality. The vast majority of CM occurs among HIV-infected people with advanced immunosuppression or within 3 months of antiretroviral therapy (ART) initiation. In sub-Saharan Africa, an estimated 7-19% of HIV-infected adults have asymptomatic cryptococcal antigenemia (CrAg) at the time of HIV diagnosis, and circulating CrAg predicts onset of CM and mortality. These antigens appear weeks before the onset of neurological symptoms, and among those with circulating antigens oral anti-fungal therapy (fluconazole) reduces the risk of CM and death. Thus, early detection of CrAg and prophylactic anti-fungal therapy might improve health outcomes, but few laboratories in resource-limited settings (RLS) have had the ability to expeditiously test for CrAg in serum.

In the first study, I worked with Ms. Julia Kleene (pictured below), a medical student at Stony Brook School of Medicine, to conduct testing of stored urine samples from a previous cohort (photos below).  In one long, exhausting day we managed to test approximately 800 urine samples using a rapid test for cryptococcal antigens.  This study was the first assessment of cryptoccocal antigen prevalence in the KwaZulu-Natal Province.  We tested participants with a wide range of CD4 counts.  We found about 10% prevalence of cryptococcosis among newly-diagnosed HIV-infected adults, and the results did not differ among people with higher CD4 counts, which is contrary to most other studies.  The results formed the basis for pilot data related to a K23 grant application and are currently being prepared for publication.

In the second study, I used the time to set up a new longitudinal study to determine the impact of clinic-based screening for cryptococcal infections at the time of HIV diagnosis.  During my visit, we were able to hire a local research assistant and a local research nurse.  We spent time at our clinical site arranging the flow of the participants through the stages of the study, preparing documents, and meeting with various research partners.  The study then started enrollment on September 12, and to date we have already enrolled over 200 participants.

The location of this study is the iThembalabantu Clinic in Umlazi, a township of Durban with over 1.2 million people and a very high burden of HIV and TB. The clinic offers HIV testing, counseling, and treatment, and has a pharmacy to dispense ART (first and second line regimens) and therapy for opportunistic infections. The clinic is staffed by 2 full-time physicians, 10 nurses, 4 HIV counselors, and a cadre of community health workers. Each day, clinic counselors test 30-40 adults for HIV, of whom an average of 36% are HIV-infected, and clinicians provide comprehensive care for >100 HIV-infected people.   The results of these studies will help inform future studies of point-of-care CrAg screening in South Africa, as well as other resource-limited settings, to help prevent AIDS-related mortality.

The travel funds provided an essential opportunity for me to travel to Durban to collect pilot data for my K23 application, and at the same time to lay the groundwork to initiate a new prospective clinical study. I have very grateful to Partners for the Global Health Center of Expertise travel grant to help support my clinical research projects.  I would definitely recommend this funding opportunity to other clinical fellows.

Cape Town, South Africa – Jessica Magidson, Postdoctoral Fellow, Chester M. Pierce, MD Division of Global Psychiatry, MGH

After leaving Harare, the second part of my trip is in Cape Town South Africa. Here I am focusing on clinical research, primarily to build relationships with faculty in the psychiatry department at University of Cape Town (UCT) who are also involved in the capacity building initiatives in Zimbabwe and the clinical research we were working on while in Harare—to train health care workers in empirically supported behavioral interventions for improving antiretroviral therapy (ART) adherence and depression. In addition to discussing with UCT faculty the ongoing progress on the work in Zimbabwe, I am also discussing ideas for future clinical and research collaborations with their team to pursue during my postdoctoral fellowship. While in Cape Town, I am also spending time at Stellenbosch University and Tygerberg Hospital in the departments of psychiatry, infectious disease, and the department of medicine to become familiar with ongoing research projects and initiatives across these departments.  

One of the projects that my team in Behavioral Medicine at MGH has been planning with faculty in psychiatry at UCT is a randomized clinical trial (RCT) to examine the effectiveness of cognitive behavioral therapy (CBT) for improving depression and ART adherence in the South African setting. In this study, CBT will be implemented by nurses working in HIV clinics in the local townships, for instance in Khayelitsha. Khayelitsha is an impoverished settlement just east of Cape Town where an estimated 500,000 people reside. Recent estimates of the HIV prevalence in this area are approximately 20%. Further, rates of depression are also very high in these areas—among individuals with HIV, it has been estimated that rates of depression reach up to about 40%. There is a huge need for treatments for depression that can be integrated into HIV care in this context.

Khayelitsha

 

A manual for improving HIV medication adherence in HIV clinics in Khayelitsha that was developed by UCT faculty and our behavioral medicine director, Dr. Safren, which incorporates modifications for this setting.

There has been some preliminary work conducted by our team and the UCT faculty to adapt existing adherence interventions such as Life-Steps and CBT for depression for this setting. The resulting intervention culturally tailored for this setting, called “Ziphamandla”, translates as ‘to be empowered’ in Xhosa. Xhosa, by the way, is one of the 11 official languages spoken in South Africa, and one of the most common spoken in the local townships such as Khayelitsha. Interestingly Xhosa has the unique feature of “click” consonants – the word Xhosa, pronounced “Kosa” also begins with a click. 

The CBT Ziphamandla intervention has been implemented thus far by two Xhosa-speaking nurses, one of whom was a psychiatric nurse, the other without previous mental health training. 14 individuals have been recruited from two of the busiest clinics in Khayelitsha, the Ubuntu and Michael Mapongwana ART clinics. The Ubuntu ART clinic was the first clinic in South Africa to offer ART and has approximately 7,000 HIV-positive patients registered in their database, the majority of whom are currently on ART. Initial results evaluating Ziphamandla seem very promising for improving depression, ART adherence, and overall functioning. The lead psychologist conducting this work, Dr. Lena Andersen, and I spent a lot of time during the visit discussing plans to disseminating the findings to the scientific community. The future RCT to compare this intervention with a control comparison condition in a larger sample will be an important future direction of this work and was an important priority for discussion throughout meetings with UCT faculty.

While in Cape Town I have also spent time at Stellenbosch University and Tygerberg Hospital to meet with faculty across different departments, including the Children’s Infectious Diseases Clinical Research Unit (KID-CRU), the psychiatry department, and the department of medicine.

During meetings at KID-CRU, although my clinical and research interests to date have largely focused on adults, we had interesting discussions regarding maternal psychosocial factors that may influence adherence and outcomes among infants and children living with HIV, as well as an emerging concern – psychosocial struggles among adolescents who are now living into adolescence and young adulthood following ART initiation from birth. 

KID-CRU, an impressive clinical research unit with its own pharmacy and laboratory, the site of numerous ongoing clinical trials focusing on improving HIV and TB outcomes among infants and children

This theme again came up while visiting the psychiatry department, where we discussed more in depth the types of psychosocial struggles among HIV-infected adolescents who have been taking ART since birth, and more specifically how factors such as substance use and impulsivity may affect adherence. It was also interesting to learn more about the structure of the psychiatry department at Stellenbosch and the different psychiatric clinical settings in the area (although I unfortunately could not visit the actual department...)

Finally, the meetings in the department of medicine were also very productive. We discussed the importance of integrating behavioral HIV research with other chronic conditions, importantly TB in this setting. We also discussed the lack of psychiatric epidemiological research to date on substance abuse among HIV-infected individuals in South Africa and ways in which initial quantitative research could lend itself to future intervention developmental efforts in an area. It is this area—the intersection of substance use, depression, and HIV self-care behaviors in both the South African and Zimbabwean context—that I hope to continue to pursue both clinically and in research.

I am extremely thankful for the opportunity to meet with faculty at UCT, Stellenbosch, and Tygerberg Hospital during this visit, for the hospitality of our gracious hosts in Zimbabwe, the support of Dr. Conall O’Cleirigh throughout the trip, as well as the mentorship in my global psychiatry fellowship from Drs. Steve Safren, Dave Henderson, and Greg Fricchione. I am very appreciative of the support from the COE travel award to enable these opportunities, particularly to be able to visit Zimbabwe for the first time. This was a fantastic experience for both clinical and research training, and I am already looking forward to the next visit to continue developing this line of clinical research and building  relationships with these clinical research teams in both Harare and Cape Town.

Early morning hike in the clouds up Table Mountain! Beautiful view of Cape Town.